<?php $this->load->view("layout/header_data_form");?>

<table width="100%" border="0" cellpadding="0" cellspacing="0">
  <tr>
    <td><h1>H &amp; S</h1></td>
    <td align="right"><img src="<?php echo img_link('small-logo.gif');?>" width="147" height="38" /></td>
  </tr>
</table>
<div id="wrap">
  <form id="form1" name="form1" method="post" action="<?php echo base_url();?>h_s/">
    <table border="0" cellpadding="5" cellspacing="0">
      <tr>
        <td width="300" align="left" valign="top"><table width="100%" border="0" cellpadding="7" cellspacing="0">
          <tr>
            <td colspan="2" align="left"><strong>Preferred:</strong></td>
          </tr>
          <tr>
            <td colspan="2" align="left"><label>
              <input type="radio" <?php echo ($row && $row->preferred == 'Private' ? 'checked="checked"' : '');?> name="Pref" id="pri2" value="Private" />
              Private </label>
                <label style=" padding-left:10px;">
                  <input type="radio" name="Pref" <?php echo ($row && $row->preferred == 'Restructured' ? 'checked="checked"' : '');?> id="pri1" value="Restructured" />
                  Restructured</label></td>
          </tr>
          <tr>
            <td colspan="2" align="left"></td>
          </tr>
          <tr>
            <td width="101" align="left">Number of Beds:</td>
            <td width="171" align="left"><select name="select" class="field" id="select">
            	<?php for($i=0; $i<=5; $i++):?>
                <option value="<?php echo $i;?>" <?php echo($row && $row->p_number_bed == $i ? 'selected="selected"' : '');?>><?php echo $i;?></option>
                <?php endfor;?>
            </select></td>
          </tr>
          <tr>
           <td colspan="2" align="left"><label>
              <input type="checkbox" <?php echo ($row && $row->p_coinsurance == 1 ? 'checked="checked"' : '');?> name="CoInsurance" id="exis3" value="Co Insurance " />
              Co Insurance </label>
                <label style=" padding-left:10px;">
                <input type="checkbox" <?php echo ($row && $row->p_deductible == 1 ? 'checked="checked"' : '');?> name="Deductible" id="exis4" value="Deductible" />
                  Deductible</label></td>
          </tr>

        </table></td>
        <td width="300" align="left" valign="top"><table width="100%" border="0" cellpadding="7" cellspacing="0">
          <tr>
            <td colspan="2" align="left"><strong>Existing:</strong></td>
          </tr>
          <tr>
            <td colspan="2" align="left"><label>
              <input type="radio" <?php echo($row && $row->existing == 'Private' ? 'checked="checked"' : '');?> name="exis" id="exis1" value="Private" />
              Private </label>
                <label style=" padding-left:10px;">
                <input type="radio" <?php echo($row && $row->existing == 'Restructured' ? 'checked="checked"' : '');?>  name="exis" id="exis2" value="Restructured" />
                  Restructured</label></td>
          </tr>
          <tr>
            <td colspan="2" align="left"></td>
          </tr>
          <tr>
            <td width="103" align="left">Number of Beds:</td>
            <td width="169"><select name="select2" class="field" id="select2">
                <?php for($i=0; $i<=5; $i++):?>
                <option value="<?php echo $i;?>" <?php echo($row && $row->e_number_bed == $i ? 'selected="selected"' : '');?>><?php echo $i;?></option>
                <?php endfor;?>
            </select></td>
          </tr>
          <tr>
            <td colspan="2" align="left"><label>
              <input type="checkbox" <?php echo ($row && $row->e_coinsurance == 1 ? 'checked="checked"' : '');?> name="CoInsurance2" id="exis3" value="Co Insurance " />
              Co Insurance </label>
                <label style=" padding-left:10px;">
                <input type="checkbox" <?php echo ($row && $row->e_deductible == 1 ? 'checked="checked"' : '');?> name="Deductible2" id="exis4" value="Deductible" />
                  Deductible</label></td>
          </tr>

        </table></td>
      </tr>
      <tr>
        <td colspan="2" align="left" valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td colspan="2" align="left" valign="top">Is your family presently covered under the same plan?: 
          <select name="select3" class="field" id="select3">
            <option <?php echo ($row && $row->has_the_same == 'Yes' ? 'selected="selected"' : '');?> value="Yes">Yes</option>
            <option <?php echo ($row && $row->has_the_same == 'No' ? 'selected="selected"' : '');?> value="No">No</option>
                              </select></td>
      </tr>
      <tr>
        <td colspan="2" align="left" valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td colspan="2" align="left" valign="top"><input type="submit" class="large button red" value="Submit"></td>
      </tr>
      <tr>
        <td colspan="2" align="left" valign="top">&nbsp;</td>
      </tr>
      <tr>
        <td colspan="2" align="left" valign="top"><a href="javascript:window.close();"><img src="<?php echo img_link('cwindow.jpg');?>" alt="Close Window" width="82" height="15" border="0" /></a></td>
      </tr>
    </table>
  </form>
  
  
</div>
<?php $this->load->view("layout/footer_data_form");?>